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LOCATION ' SEW&CIE PER/MIT UO.
IIVSTQL ER-S W&NAE /ADDRESS
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BUILDERS,{.. Q & E ADDRESS ,
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DNTE PERMIT ISSUED
DATE COMPLI &MICE ISSUED ; - - -
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--------- OF....... ..46,j5&�. . ..................
Application is hereby-made for u Permit to Construct [ } or Repair ( ) an Individual Sewage Disposal
System |
' ___'---_'-_-_'_-__------__-----_---------...
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Add
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Type of Size -_.Sn feet
� Building- �� � ^ �
Dwellingo6 .-1� - . -- ( ) Cu,bugc Grinder ( ) �
0-1 Other--Type of Building 61fet No. of peranns--'-� --------------- Showers (z,.) -- Cafeteria ( )
Otherfixtures ------------- .................................--'---------------------------------------------------------------------------'------
� Desigo per person per day. Total 6nJy flow-' --''gaDoos
Septic Tank '�� Lcugtb.----' �V�th-----. Diameter Dq«\`------
Disposal Trench--0u '_- Width Total leaching h.
'- So�yn�� ��t BJo--- "�.-.- D�um'gcr. leaching area------'sq. It.
� Ot6crD�� �x ( ) �� t� ( � ��
~~ Percolation Tot Results Performed by-----------------------.---- Date-------------'
� Tcs Pit No. l----------------minntesPerinc6 I)ent6 of Test Pit.. ----_- Depth to -round water ------'
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-.-------------------___-----_----------------_.---_-_--.--''--'----- .
U DJatocc of Repairs or Alterations—Answerwhen applicable.-. --.-------------.------------.--'
------------I
The undersigned agrees to install the uforodeocribed Individual Sewage Disposal System in accordance with
the provisions of Article %lof the State Sanitary Code— The undersigned further agrees not mplace the system in
operation until a Certificate o6Compliance
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AoPlicutiou Approved Dy- �'��- ' -.--'.--'-' -'- ���---_'�^�-_.-
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Application Disapproved for the following reasons:................................................................................................................
-----------'-----'----------'-'----'------------'---'-----------'----
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PermitNo......................................................... Issued.........................................................
L' - - -''-'' -'-'--'---'_- - -' '_ - - -' '- '--' --- ' --''' - ---_'J
No........•........-.......
F�$.. ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O WEAL-THK- 1
Appliratiun -fur 'MiVni tt1 Vvies Tomitrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
. %ll ... - ` ---------------=
JLocation Af •Ad ---- (� t or Lot No.
W i Owner -_Z& ....... Add
Installer Address
Type of Building Size Lot...::------ .:... ........Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
C14 Other—Type of Building !..................I....... No. of persons---------- --------------- Showers Cafeteria ( )
Q' Other fixtures
d -•-----••-----------------------------------...--•---.......--•---•---•••--- ----------- ----------------------
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W Design Flow-- .........5?J..........gallons per person per day. Total daily flow...................?.o:np.............gallons.
P� Septic Tank—Liquid capacity__✓z6agallons Length---------------- Width-----........... Diameter................ Depth..--------------
x Disposal Trench—No..................... Width------------
_ - Totaa Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No---------/........ Diameter... De th beltii'et� Q?l' Total leachingarea. __.__.-.--_-_sc it.
Z Other Distribution box ( ) Dosing tank ( ) ),b _ //G — / d .� - 7
aPercolation Test Results Performed by------------------------•-................................................ Date........................................
Test Pit No. 1................minutes per inch Depth of "Pest Pit..------------------ Depth to ground water.--.----_.--_-----.--. -
�14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
----------
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Description of Soil- =_ - �f� GYc1` •� r --
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x ---------------- -----------•-- ---------------------------------------------------- ............ -------------------------=------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable.-.---_...................................._........_......._.,_.___...._.__.__-__._..._....._
----------------------------•------------------------------------------------------------------------------------------------------------------------------._----------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenjss6ed by the board of health.
Sign '/ -----------------------• •----•-•--•----•--•-----------
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Date �ryt
Application Approved By..... . .. .. ....� LG�.... "'' ��__.._..-__
Date
Application Disapproved for the following reasons:._._.. —-- -----•------------------------------------------------------------------------------------------------
-------------•---------•---•----•--•----------------•---•--•--•-•-----------•-•-----•---•---•--------•--------•--•------------------•-•------.----•-•-------------------------------------•-------.-----
Date
PermitNo.......................................................................... Issued--------...-----••----- ................................
' Datee
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF........... �...... ..... . ....../�.. '...............
%:krrtifirate of fI'limp atta
THIS IS TO CE TIFY at the Individual Sewage Disposal System constructed or Repaired ( )
by..:...... 1 ------ -------------------- -----------------------------------------------------------------------------------•--•------------
1 Ins atl r
has been installed in accordance with the provisions of Icle XI of The State................... dated Sanitary-----1�_`_.__ .Code as described in the
application for Disposal Works Construction Permit No._-....yU... _ .''-_7.-S'....._.._.
-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------------------------------------------------•---•-----••----••-• Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.ti
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No---- F ....................
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Permission is ereby granted---------- ..._... .............. •-----------------------------------------....._--------•---••----..••••-
to Construct'14 or Repair �fn Individu Sewage Dy;'posal System
at No.- 11 .-. ,._.. N.�
- ---------•--•--•-•-----------•--------•------•-------
!� Street -
as shown on the application for Disposal Works Construction Per x No.,n1,..G�__...__ Dated----� .. 7- 7S
. ............................•-
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F1 � Board �HeStf
DATE 0�'�-f -`------------------7 --------------------------- 1
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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